Orthopedics

Feature Article Supplemental Data

Same-Day Discharge Following Total Joint Arthroplasty: Examining Trends, Discharge Dispositions, and Complications Over Time

Julien Clouette, BSc; Avinesh Agarwalla, MD; Bheeshma Ravi, MD, PhD, FRCSC; Rajiv Gandhi, MD, MSc, FRCSC; Naomi Maldonado-Rodriguez, BKIN; Bryan M. Saltzman, MD; Anthony A. Romeo, MD; Timothy S. Leroux, MD, Med, FRCSC

Abstract

Administrative database studies have reported on the safety of same-day discharge (SDD) following total joint arthroplasty (TJA); however, most patient cohorts have been defined by length of stay (LOS), and the proportion discharged directly home remains unknown. The purpose of this investigation was to (1) determine common dispositions for patients undergoing SDD TJA; (2) understand changes in discharge disposition over time; and (3) determine the safety of SDD TJA, stratified by discharge disposition. The PearlDiver Database was reviewed for patients who underwent SDD TJA (LOS of 0 days) from 2011 to 2016. Patients were stratified by discharge disposition, and rates and complications following SDD TJA were assessed accordingly. Chi-square analysis was performed to compare demographics and complications between patient groups stratified by disposition. From 2011 to 2016, there was an exponential increase in the annual rate of SDD TJA from 0.95% to 20.5%, respectively; however, the annual proportion of patients discharged directly home remained unchanged (approximately 68%), with the remaining discharged directly to an alternate care facility, most commonly inpatient rehabilitation. Patients discharged to an alternate facility were significantly older (P<.001), had significantly higher comorbidity scores (P<.001), and had significantly more complications (P<.001) than those patients discharged directly home. Although the annual rate of SDD TJA is increasing, up to one-third of patients are not discharged directly home—a proportion unchanged over time. Moving forward, administrative database studies examining SDD TJA must account for discharge disposition; moreover, there is a need to understand the practice of SDD TJA to an alternate care facility. [Orthopedics. 2020;43(4):204–208.]

Abstract

Administrative database studies have reported on the safety of same-day discharge (SDD) following total joint arthroplasty (TJA); however, most patient cohorts have been defined by length of stay (LOS), and the proportion discharged directly home remains unknown. The purpose of this investigation was to (1) determine common dispositions for patients undergoing SDD TJA; (2) understand changes in discharge disposition over time; and (3) determine the safety of SDD TJA, stratified by discharge disposition. The PearlDiver Database was reviewed for patients who underwent SDD TJA (LOS of 0 days) from 2011 to 2016. Patients were stratified by discharge disposition, and rates and complications following SDD TJA were assessed accordingly. Chi-square analysis was performed to compare demographics and complications between patient groups stratified by disposition. From 2011 to 2016, there was an exponential increase in the annual rate of SDD TJA from 0.95% to 20.5%, respectively; however, the annual proportion of patients discharged directly home remained unchanged (approximately 68%), with the remaining discharged directly to an alternate care facility, most commonly inpatient rehabilitation. Patients discharged to an alternate facility were significantly older (P<.001), had significantly higher comorbidity scores (P<.001), and had significantly more complications (P<.001) than those patients discharged directly home. Although the annual rate of SDD TJA is increasing, up to one-third of patients are not discharged directly home—a proportion unchanged over time. Moving forward, administrative database studies examining SDD TJA must account for discharge disposition; moreover, there is a need to understand the practice of SDD TJA to an alternate care facility. [Orthopedics. 2020;43(4):204–208.]

In an attempt to reduce the cost of total joint arthroplasty (TJA) procedures1–5 and to improve patients' recovery experience,2,6,7 hospitals and clinicians have moved toward a reduced length of stay (LOS). Improvements in surgical techniques,8 patient selection criteria,9–11 perioperative anesthesia,7,12 and rehabilitation protocols7,12 have enabled this shift toward same-day discharge (SDD) TJA. Clinical studies, database analysis, and systematic reviews seem to be offering positive results regarding the safety of SDD TJA7,13–19; however, many of these studies fail to account for several limitations and thus may not be generalizable to all surgical practices and patients.

First, clinical studies usually involve high-volume surgeons with experienced medical teams, optimizing the surgical conditions.3,5,8,12,18–21 This does not represent the average surgeon around the world who occasionally performs TJA and who may choose to discharge patients on the day of surgery, despite a lack of experience and support. Second, the term “outpatient” or “same day discharge” has not been clearly operationalized in the past.22 While some studies define it to be a discharge on the day of the surgery (postoperative day 0), others define it to be a discharge less than 23 or 24 hours after the surgery, which can involve staying in the hospital overnight.10,23–25 Finally, many database studies do not identify discharge disposition, whereby some patients may not be discharged directly home but rather to an alternate inpatient care facility such as inpatient rehabilitation or a skilled nursing facility (SNF). As such, it remains unclear what proportion of patients undergoing SDD TJA are truly discharged home and how this impacts the findings of these large database studies that often report SDD TJA to be safe and cost-effective.3

Given the above-mentioned limitations, the purpose of this study was to (1) determine common dispositions for patients undergoing SDD TJA, (2) understand changes in discharge disposition over time, and (3) determine the safety of SDD TJA, stratified by discharge disposition.

Materials and Methods

Database

A retrospective review of the Humana patient data within the PearlDiver Patient Records Database (PearlDiver, Fort Wayne, Indiana) from 2011 through 2016 was conducted. This database represents more than 20 million patients in the United States, containing data regarding patient demographics, hospitalization details, diagnoses, procedures, and reimbursement. All data are accessed with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedural codes, International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) procedural codes, and Current Procedural Terminology (CPT) codes. The database was searched for patients undergoing shoulder, hip, or knee TJA between 2011 and 2016 with a discharge following a LOS of 0 days. The accessed data represented procedures and diagnoses that were billed to the insurance company by the provider during that period. All information in this database is de-identified and anonymous.

Study Cohorts

Patient cohorts were created for those undergoing total shoulder arthroplasty (TSA), total knee arthroplasty (TKA), and total hip arthroplasty (THA) based on ICD-9 and ICD-10 procedural codes (Table A, available in the online version of the article). Patients were also combined to formulate a TJA group (TJA; THA+TKA+TSA). Procedural codes were queried instead of CPT codes because procedural codes are coded by hospital systems and contain information regarding LOS and discharge disposition.

Table A:

Patients were excluded if they underwent revision surgery or did not have at least 30 days of follow-up data. In patients with multiple arthroplasties of the same joint (ie, bilateral knee arthroplasty), only the initial procedure was accounted for in this study. Only patients undergoing TJA with a LOS of 0 days were included. Discharge disposition was determined using disposition records and was classified as discharge to (a) home (with and without home health aid), (b) rehabilitation facility, (c) SNF, or (d) nursing home. Medical- and procedure-specific complications were queried in the database based on ICD diagnosis codes.

Study Outcomes

The primary outcome of this study was common discharge dispositions following SDD TJA. Secondary outcomes included (1) the annual change in the rate of SDD TJA over time, (2) annual changes in discharge disposition over time, and (3) differences in demographics and complication rates between patients undergoing SDD TJA with different discharge dispositions.

Statistical Analysis

Changes in the annual rate of SDD TJA were determined between 2011 and 2016. This was calculated by reporting the number of SDD TJA procedures in a single year divided by the total number of TJA procedures in the same year. The rate was calculated overall and by specific joint replacement type (TSA, THA, and TKA). The annual rate of SDD TJA with a discharge directly home or to another care facility was similarly calculated.

Descriptive statistics were applied as well as bivariate analysis to compare demographic factors for those who underwent SDD TJA with a discharge directly home vs to other facilities. Continuous variables were compared with the Student's t test (after completing tests of normality) and categorical variables were compared with the chi-square test or Fisher's exact test to assess statistical significance. All statistical testing was performed using a 2-tailed hypothesis at a significance of P≤.05. Discrete variables were reported with frequencies and percentages, while continuous variables were reported with means and standard deviations. Statistical analysis was conducted using Excel (Microsoft, Seattle, Washington).

Results

Overall, 190,694 patients (THA: 63,249; TKA: 112,476; TSA: 14,969) underwent a TJA procedure between 2011 and 2016, of whom 9% were discharged on the same day (THA: 9.5%, N=6000; TKA: 8.6%, N=9684; TSA: 10.2%, N=1540). When examined annually, the data showed an exponential increase in the annual rate of TJA with a discharge on the same day from 0.95% in 2011 to 20.5% in 2016 (Figure 1, Table 1).

The exponential increase in patients discharged on the day of surgery after a total joint arthroplasty (TJA). Abbreviations: THA, total hip arthroplasty; TKA, total knee arthroplasty; TSA, total shoulder arthroplasty.

Figure 1:

The exponential increase in patients discharged on the day of surgery after a total joint arthroplasty (TJA). Abbreviations: THA, total hip arthroplasty; TKA, total knee arthroplasty; TSA, total shoulder arthroplasty.

Proportion of Same-Day Discharge Total Joint Arthroplasties Performed Annually—Overall and by Specific Joint Replacement

Table 1:

Proportion of Same-Day Discharge Total Joint Arthroplasties Performed Annually—Overall and by Specific Joint Replacement

Among the 17,224 TJA patients discharged on the same day, 9956 (57.8%) had specified discharge disposition. For these patients, the annual rate of TJA with a discharge directly home did not differ between 2011 and 2016 (Table 2), with a mean rate of 61.41%, 70.03%, and 86.55% of patients going directly home following SDD THA, TKA, and TSA, respectively (P>.05). Of the approximately 32.4% of SDD TJA patients who were not discharged home during the study period, most were discharged to an inpatient rehabilitation center (90.1%) and a few to a SNF (9.3%). Table 2 details the distribution of patients to alternate care facilities, by year and by joint replaced.

Annual Proportion of Same-Day Discharge Total Joint Arthroplasties Discharged Home Versus Alternate Care Facility

Table 2:

Annual Proportion of Same-Day Discharge Total Joint Arthroplasties Discharged Home Versus Alternate Care Facility

Patients discharged directly home were significantly younger and had a significantly lower Charlson Comorbidity Index. A significantly higher proportion were male compared with those discharged to an alternate care facility (Table B, available in the online version of the article); moreover, patients discharged to an alternate care facility had significantly more complications overall and among each type of joint replacement (P<.001) than patients discharged directly home (Table C, available in the online version of the article).

A comparison of the rates of complications of same-day discharge total joint arthroplasties going home vs alternate care facility (“elsewhere”)1

Table B.

A comparison of the rates of complications of same-day discharge total joint arthroplasties going home vs alternate care facility (“elsewhere”)

Demographics of same-day discharge total joint arthroplasties going home vs alternate

Table C.

Demographics of same-day discharge total joint arthroplasties going home vs alternate

Discussion

The results of this study indicate that the proportion of SDD TJA procedures increased exponentially between 2011 and 2016; however, this analysis showed that approximately one-third of these patients were discharged to a location other than home, most commonly an inpatient rehabilitation facility. Moreover, these results showed that patients discharged to an inpatient rehabilitation facility were significantly older, had a higher body mass index, and reported a higher rate of comorbidities compared with patients discharged directly home on the same day of surgery. It is likely that this difference in demographics and health accounted for the higher complication rate among patients discharged to a rehabilitation facility compared with those discharged directly home on the same day of surgery.

While clinical studies reporting on SDD TJA identify discharge,3,5,18,19,21 administrative database studies that have formed the large bulk of our understanding of SDD TJA7,10,13–17,23,24,26,27 often fail to define it and the assumption is that these patients are going directly home. Unfortunately, the current authors found this assumption not to be true, as up to one-third of patients were not discharged directly home. Additionally, the authors found that stratifying by discharge disposition did influence the findings, whereby patients undergoing SDD TJA with a discharge directly home were significantly younger and healthier than patients undergoing SDD TJA with a discharge to an alternate care facility. Given that discharge disposition has not commonly been used to define a patient cohort in past database studies pertaining to SDD TJA, these studies may have misrepresented the characteristics of patients truly discharged home on postoperative day 0. For this reason, surgeons need to be mindful that some past studies on this topic were biased by the inclusion of older, more medically complex patients, who make up almost one-third of the reported data, and that the assumption that patients with LOS of 0 days all go home is incorrect.

Perhaps the most interesting observation of this study was the realization that up to one-third of patients with a LOS of 0 days following TJA do not actually go home but rather to an alternate care facility. The rationale for this practice is unclear. One rationale would be cost, whereby the cost of the inpatient stay at a facility other than the hospital may be less. This is a particularly important consideration in the current episode-of-care funding model, where hospitals are given fixed reimbursement to cover the surgery and up to 90 days of postoperative care. A second explanation may be a need to manage bed space, whereby TJA volume is disproportionately higher than the bed space capacity of the hospital. Discharging patients who are otherwise not amendable to immediate discharge home but are perhaps healthy enough to be cared for in a step-down or transitional facility to an alternate care facility would be one strategy to balance surgical and ward capacity. While the first two rationales are likely the main reasons for SDS to an alternate care facility, a third and more controversial rationale may be the displacement of complications. For instance, some complications that occur in an alternate care facility may go unreported in databases such as the National Surgical Quality Improvement Program,14 which would lead to a lower complication rate at the index hospital. Interestingly, the alternative practice of an admission and in-hospital stay has historically led to a tendency for complication over-reporting in comparison with other facilities and home,14 which may further encourage hospitals to develop relationships with other inpatient care facilities where patients are still receiving medical care but outside hospital walls. Future studies should seek to uncover the true reasons for this seemingly common practice and to further understanding of both the risks and benefits of this practice in relation to patient safety, satisfaction, and cost. Further research will allow hospitals to establish guidelines regarding the stratification of discharge dispositions based on patients' conditions.

While this study provides a large-scale description of SDD TJA, its results should be viewed within the context of the limitations inherent to administrative database studies, including errors in reporting (accuracy of billing codes, miscoding/non-coding by physicians) and a lack of details pertaining to severity of the disease/medical comorbidities and the procedure. Important to the current study and others moving forward, disposition data were only available for approximately 60% of the overall TJA cohort. The reason for this is unclear; it may simply be due to insufficient reporting by individual hospitals. Despite this, the sample of patients with available information pertaining to discharge disposition was still sizeable and is generalizable to most patients undergoing TJA.

Conclusion

Although SDD TJA is increasing in frequency on an annual basis, up to one-third of patients are not discharged directly home—a proportion that remains unchanged over time. Moving forward, it is imperative that large administrative databases examining SDD TJA account for discharge disposition; moreover, there is a need to better understand the practice of SDD to an alternate care facility, specifically regarding rationale, cost, and patient outcomes.

References

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Proportion of Same-Day Discharge Total Joint Arthroplasties Performed Annually—Overall and by Specific Joint Replacement

YearTHATKATSATJA
20111.05%0.84%1.66%0.95%
20121.41%1.46%2.12%1.49%
20132.18%2.49%3.06%2.44%
20146.50%6.94%7.01%6.80%
201512.16%12.32%13.41%12.35%
201620.07%20.87%20.03%20.49%

Annual Proportion of Same-Day Discharge Total Joint Arthroplasties Discharged Home Versus Alternate Care Facility

YearTHATKATSATJA




HomeAlternate FacilityHomeAlternate FacilityHomeAlternate FacilityHomeAlternate Facility
201169.57%30.43%67.09%32.91%92.31%7.69%70.30%29.71%
201268.00%32.00%59.71%40.29%75.00%25.00%63.48%36.52%
201365.87%34.13%63.00%37.00%87.50%12.50%65.66%34.34%
201468.90%31.10%70.09%29.91%85.45%14.55%70.82%29.18%
201563.74%36.26%69.80%30.20%88.54%11.46%69.55%30.45%
201657.23%42.77%71.54%28.46%85.56%14.44%67.59%32.41%
ProcedureICD-9/10 Procedural Codes
Total Knee Arthroplasty815.4, 0SRC07Z, 0SRC0J9, 0SRC0JA, 0SRC0JZ, 0SRC0KZ, 0SRD0J9, 0SRD0JA, 0SRD0JZ, 0SRD0KZ, 0SRT0J9, 0SRT0JA, 0SRT0JZ, 0SRU0J9, 0SRU0JA, 0SRU0JZ, 0SRU0KZ, 0SRV0J9, 0SRV0JA, 0SRV0JZ, 0SRW0J9, 0SRW0JA, 0SRW0JZ, 0SRW0KZ
Total Hip Arthroplasty815.1, 0SRR019, 0SRR01A, 0SRR01Z, 0SRR039, 0SRR03A, 0SRR03Z, 0SR9019, 0SR901A, 0SR901Z, 0SR9029, 0SR902A, 0SR902Z, 0SR9039, 0SR903A, 0SR903Z, 0SR9049, 0SR904A, 0SR904Z, 0SR907Z, 0SR90J9, 0SR90JA, 0SR90JZ, 0SR90KZ, 0SRA009, 0SRA00A, 0SRA00Z, 0SRA019, 0SRA01A, 0SRA01Z, 0SRA039, 0SRA03A, 0SRA03Z, 0SRA07Z, 0SRA0J9, 0SRA0JA, 0SRA0JZ, 0SRA0KZ, 0SRB019, 0SRB01A, 0SRB01Z, 0SRB029, 0SRB02A, 0SRB02Z, 0SRB039, 0SRB03A, 0SRB03Z, 0SRB049, 0SRB04A, 0SRB04Z, 0SRB07Z, 0SRB0J9, 0SRB0JA, 0SRB0JZ, 0SRB0KZ, 0SRE009, 0SRE00A, 0SRE00Z, 0SRE019, 0SRE01A, 0SRE01Z, 0SRE039, 0SRE03A, 0SRE03Z, 0SRE0J9, 0SRE0JA, 0SRE0JZ, 0SRR07Z, 0SRR0J9, 0SRR0JA, 0SRR0JZ, 0SRR0KZ, 0SRS019, 0SRS01A, 0SRS01Z, 0SRS039, 0SRS03A, 0SRS03Z, 0SRS0J9, 0SRS0JA, 0SRS0JZ, 0SRS0KZ
Total Shoulder Arthroplasty81.80, 81.88, 0RRJ00Z, 0RRK00Z, 0RRJ00Z, 0RRJ07Z, 0RRJ0J6, 0RRJ0J7, 0RRJ0JZ, 0RRJ0KZ, 0RRK07Z, 0RRK0J6, 0RRK0J7, 0RRK0JZ, 0RRK0KZ, 0RR00Z

A comparison of the rates of complications of same-day discharge total joint arthroplasties going home vs alternate care facility (“elsewhere”)1

THATKATSATJA

Home (%)Elsewhere (%)p-valueHome (%)Elsewhere (%)p-valueHome (%)Elsewhere (%)p-valueHome (%)Elsewhere (%)p-value
Total27.0152.39p<0.00124.1940.87p<0.00126.0754.33p<0.00125.2647.61p<0.001
Acute Kidney Injury5.7814.40p<0.0013.929.98p<0.0014.2813.39p<0.0014.527.79p<0.001
Cardiac Arrest0.180.72p=0.010.140.28p=0.26000.140.31p=0.06
Deep Vein Thrombosis2.596.87p<0.0013.88.3p<0.0011.717.09p<0.0013.203.66p=0.22
Nerve Injury1.001.37p=0.300.780.83p=0.852.082.36p=0.841.001.21p=0.32
Pneumonia3.0910.71p<0.0011.965.35p<0.0013.437.87p=0.0182.475.78p<0.001
Pulmonary Embolism1.233.18p<0.0011.893.14p=0.0030.732.36p=0.791.561.64p=0.74
Surgical Site Infection3.415.43p=0.0033.235.24p<0.0011.962.36p=0.763.142.92p=0.54
Urinary Tract Infection11.2326.05p<0.00110.4619.75p<0.00112.4833.08p<0.00110.9215.64p<0.001
Dehiscence1.912.46p=0.261.682.21p=0.160.491.57p=0.151.611.24p=0.15
Hematoma1.051.52p=0.210.920.66p=0.310.611.57p=0.240.920.87p=0.78
Transfusion5.5512.01p<0.0012.576.51p<0.0013.1810.24p<0.0013.546.36p<0.001
Dislocation2.273.18p=0.100.420.99p=0.0082.457.09p=0.0051.212.27p<0.001

Demographics of same-day discharge total joint arthroplasties going home vs alternate

THATKATSATJA

Home (%)Elsewhere (%)p-valueHome (%)Elsewhere (%)p-valueHome (%)Elsewhere (%)p-valueHome (%)Elsewhere (%)p-value
Age > 65 y70.2688.28p<0.00174.3785.93p<0.00180.2990.55p=0.00573.7989.79p<0.001
Male Gender44.7931.48p<0.00141.0929.12p<0.00143.7012.60p<0.00142.5130.38p<0.001
Obesity (30–39 kg/m2)22.1420.19p=0.1726.7628.63p=0.1425.2123.62p=0.7025.1925.70p=0.58
Morbid Obesity (≥40kg/m2)9.0011.79p=0.00714.2622.06p<0.00112.1214.96p=0.3712.4218.06p<0.001
Tobacco Use33.2934.30p=0.5328.7428.19p=0.6633.9035.43p=0.7431.2831.97 4.66p=0.47
Alcohol Abuse3.775.93p=0.0032.623.31p=0.145.886.30p=0.853.34p=0.001
Comorbidities Diabetes Mellitus27.3341.03p<0.00134.7247.55p<0.00137.8243.31p=0.2432.8346.06p<0.001
Hyperlipidemia68.5878.00p<0.00174.5182.57p<0.00178.4680.31p=0.6373.1683.09p<0.001
Hypertension71.8585.24p<0.00178.3186.38p<0.00182.7492.13p=0.00776.8588.80p<0.001
Peripheral Vascular Disease11.3220.41p<0.00110.9020.13p<0.00113.5920.47p=0.04011.3320.89p<0.001
Congestive Heart Failure8.5424.31p<0.00111.2319.58p<0.00114.3222.83p=0.01410.7722.34p<0.001
Coronary Artery Disease21.1532.49p<0.00124.4732.98p<0.00130.1131.49p=0.7524.1033.74p<0.001
Chronic Kidney Disease14.1029.31p<0.00115.8629.73p<0.00119.0929.92p=0.00515.7030.48p<0.001
Chronic Lung Disease17.9629.23p<0.00117.5425.48p<0.00124.6036.22p=0.00618.4628.31p<0.001
Chronic Liver Disease6.147.02p=0.307.038.27p=0.098.208.66p=0.866.908.01p=0.04
Depression21.3231.62p<0.00125.5432.38p<0.00131.0943.21p=0.00624.8933.49p<0.001
CCI1.65 +/−2.272.99 +/−3.081.76+/−2.142.78 +/−2.762.32+/−2.742.89 +/−3.071.79+/−2.262.87 +/−2.91
Authors

The authors are from the Department of Orthopaedic Surgery (JC, RG, NM, TSL), University Health Network, Toronto, Ontario, Canada; the Department of Orthopaedic Surgery (AA), Westchester Medical Center, Valhalla, New York; the Department of Orthopaedic Surgery (BR), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; the Department of Orthopaedic Surgery (BMS), Rush University Medical Center, Chicago, Illinois; and the Department of Orthopaedic Surgery (AAR), Rothman Orthopaedics, Westchester, New York.

Mr Clouette, Dr Agarwalla, Dr Ravi, Ms Maldonado-Rodriguez, Dr Saltzman, Dr Romeo, and Dr Leroux have no relevant financial relationships to disclose. Dr Gandhi is a paid consultant for DePuy Synthes.

Correspondence should be addressed to: Avinesh Agarwalla, MD, Department of Orthopaedic Surgery, Westchester Medical Center, 100 Woods Rd, Valhalla, NY 10595 ( avinesh.agarwalla@icloud.com).

Received: November 27, 2019
Accepted: March 28, 2020
Posted Online: May 05, 2020

10.3928/01477447-20200428-03

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